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SEE/BOARD STUDY AA > APEX: Monitoring I Respiratory > Flashcards

APEX: Monitoring I Respiratory Flashcards

1
Q

CO2 Waveform consistent with obstruction can show

A

Elevated peak with normal plateau pressure

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2
Q

Conditions associated with elevated peak pressure and normal plateau pressure : ETT

A

Kinked ETT

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3
Q

Conditions associated with elevated peak and normal plateau pressure : lungs and other

A

Bronchospasm

Aspiration of foreign body

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4
Q

What is elevated peak pressure and normal plateau pressure indicates?

A

Reduction in dynamic compliance caused by increased airway resistance.

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5
Q

Assessment of Pulmonary Resistance and compliance: Resistance formula

A

Resistance = P(airway) - P (alveolar) / Gas flow rate

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6
Q

Defined as the force that acts opposite to the relative motion of an object?

A

Resistance

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7
Q

What is the definition of compliance?

A

Change in Volume/ change in pressure

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8
Q

Change in volume for a given changes in pressusre

A

Compliance

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9
Q

What does compliance measure?

A

The elastic properties of the lungs and chest wall

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10
Q

What is compliance influenced by? DAMAP

A 
Degree of lung inflation
Alveolar surface tension
Muscle tone
Amount of interstitial lung water
Pulmonary fibrosis
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11
Q

What is dynamic compliance?

A

The compliance of the lungs /chest wall DURING air movement

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12
Q

Dynamic compliance is the pressure

A

required to inflate the lung to a given volume is a

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13
Q

Static means

A

Not moving

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14
Q

Static compliance measures

A

Lung compliance where there is NO AIRFLOW

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15
Q

Static compliance is the pressure

A

required to keep the lung inflated to a given volume

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16
Q

Static compliance is the function

A

of the tendency of the lung/chest to collapse. Since there is no airflow during this measurement there is no resistance to overcome

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17
Q

Dynamic compliance is a function of

A

Function of AIRWAY RESISTANCE and the TENDENCY OF THE LUNG/CHEST WALL to COLLAPSE

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18
Q

The significance of peak inspiratory pressure and plateau pressure

A

The peak inspiratory and plateau pressure provide key insight to a patient’s airway resistance and LUNG-THORACIC COMPLIANCE

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19
Q

Peak inspiratory Pressure (PIP)

A

Is the maximum pressure in the patient’s airway during inspiration

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20
Q

What is PIP affected by?

A

Because air flow is flowing into the airway during inspiration, PIP is affected by airway resistance and lung-thoracic compliance

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21
Q

Dynamic compliance FORMULA

A

Tidal volume / Peak pressure- PEEP

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22
Q

What is plateau pressure?

A

the pressure in the small airways and alveoli after the target TV is delivered.

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23
Q

Plateau pressure is the pressure in the small airways and alveoli after the target TV is delivered. Does airway resistance affect plateau pressure? why/why not?

A

Since there is no airflow at this time, airway resistance does not affect plateau pressure.

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24
Q

Plateau pressure reflects the

A

elastic recoil of the lungs and thorax during the inspiration pause (no gas i s moving in or out) of the lungs

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25
What is BAROTRAUMA risk is high ?
Risk increases when plateau pressure exceeds 35cm/H2O
26
What are complications of ELEVATED plateau pressure?
Ventilator-associated lung injury Pneumothorax Pneumomediastinum SC emphysema
27
IF Barotrauma exists, you should aim to
Reduce plateau pressure by reducing TV, inspiratory flow and PEEP. Sedation is helpful
28
Static compliance formula
Tidal volume / Plateau pressure - PEEP
29
In the adult, the normal static compliance is
35-100 ml/cm H2O
30
In the Child, the normal static compliance is
>15cm /cm H2O
31
If PIP is increase and PP increase then: Total complaince has ________or TV has _______
Total compliance has decreased | TV has increased
32
If PIP is increased and no changed in PP then: Total compliance has________ or TV has _______
Resistance has increase OR Inspiratory flow rate has increased.
33
Compliance with : Endobronchial intubation?
Decreased
34
Compliance with : Pulmonary edema
Decreased
35
Compliance with : Pleural effusion
Decreased
36
Compliance with : Tension pneumothorax
Decreased
37
Compliance with : Atelectasis
Decreased
38
Compliance with : Chest wall edema
Decreased
39
Compliance with : Abdominal insufflation
Decreased
40
Compliance with : Ascites
Decreased
41
Compliance with : Trendelenburg position
Decreased
42
Compliance with : Inadequate muscle relaxation
Decreased
43
Increase resistance in airway with
Bronchial secretion Compression of the airway ETT cuff HERNIATION FB aspiration
44
Phase I (A-B) represents
Exhalation of anatomic dead space (flat before phase II)
45
Phase II (B-C) represents
Exhalation of anatomic dead space+ ALVEOLAR GAS.
46
Upstroke is phase
II
47
Phase III (C-D) represents
exhalation of alveolar gas.
48
Plateau phase is
III
49
Phase IV represents
Inspiration of fresh gas that DOES NOT CONTAIN CO2
50
Illustrated by return of waveform to baseline
Phase IV
51
Capnography measures
ETCO2 concentration over time.
52
Capnography measures 3 main things?
Assessment of metabolism Circulation Ventilation
53
CO2 concentration gradient
From the tissues to the breathing circut
54
What is the final product of aerobic metabolism?
Carbon dioxide
55
CO2 diffuses airway then from the tissues on, what happen?
from the tissue and enters the venous circulation, From here, the CO determines the rate of transfer towards the lungs. In the lungs, CO2 follows a concentration gradient as it diffuses across the alveolar capillary membrane. Once the CO2 in the alveolus, ventilation is the process by which CO2 is removed from the body
56
What point in the CO2 waverform is ETCO2 measure?
Point D
57
Normal ETCO2
35-40 mmHg
58
The alpha angle is
Airway obstruction reading
59
Where is the alpha angle measure?
Point C
60
Normal alpha angle is
100-110 degreers
61
An increase alpha angle means
EXPIRATORY AIRFLOW OBSTRUCTION such as COPD, bronchospasm or a KINKED ETT TUBE.
62
Alpha angle is between
the first expiration upstroke and the plateau line
63
Beta angle is
REBREATHING reading
64
The beta angle is measure at what point
point D
65
When the patient inspires, the capnography should immediately
return to zero because fresh gas flow does not contain CO2
66
The beta angle is increased indicating
Rebreathing
67
Causes of Rebreathing
Faulty unidirectional valves | Exhausted CO2 absorbent
68
If Expiratory vale is faulty you will notice 2 things about the waveform
Beta angle become WIDER DURING INSPIRATORY | Baseline does not return to zero
69
Middle of case expiratory valve malfunction
Increased the FGF to finish case | after, took valve assembly and flipped the disc over
70
2 Methods of CO2 analysis
Mainstream (in line) | Sidestream (diverting )
71
In what CO2 analysis methods is the device attached to the ETT
Mainstream (in line)
72
What CO2 analysis method has a faster response time,
Mainstream , does not require a water trap or pumping mechanism
73
Benefits mainstream (in line) CO2 analysis
Because it's attached to the ETT , it does not increase apparatus dead space as well as adds extra weight
74
Sidestream (diverting) CO2 analysis location
Located outside of the airway
75
Sidestream uses what kind of mechanism?
A pumping mechanism continuously aspirate the gas sample from the breathing circuit, and for this reason, the response time is slower.
76
CO2 analysis method with a water trap
Sidestream ; to prevent contamination of the device.
77
Identify caused of the abnormal waveform if there is a PROLONGED UPSTROKE
Airflow obstruction
78
Identify caused of the abnormal waveform if there is a INCREASED ALPHA ANGLE
Airflow obstruction COPD Bronchospasm Kinked ETT
79
Identify caused of the abnormal waveform if there is a CARDIAC OSCILLATION
Heart beating against the lungs
80
CARDIAC OSCILLATION more common in ? why?
In children, close proximity of heart to the lungs
81
Identify caused of the abnormal waveform if there is a CURARE CLEFT
Spontaneous breaths during mechanical ventilation
82
Identify caused of the abnormal waveform if there is a CURARE CLEFT, If presents during spontaneous ventilation , suggests
INADEQUATE MUSCLE RELAXANT (lack of synchronizaiton between intercostal muscles and diaphragm)
83
Low ETCO2 indicates
Hyperventilation Decrease CO2 production Increased alveolar dead space
84
BP and CO2
Hypotension leads to CO2 production
85
Elevated ETCO2 with normal plateau?
Make sure you look at the baseline and that it returns to zero. Its not rebreathing. Occurs with increased production of CO2 or DECREASED ALVEOLAR VENTILATION
86
Baseline not returning to zero is
rebreathing
87
Inadequate FGF with mapleson circuit lead to
Rebreathing
88
Widened beta angle
Incompentent unidirectional valve
89
Patient with single lung transplant and CO2 waverform
Alveolar gas from transplanted lung and the diseased lung have different time constants The first peak is alveolar GAS FROM TRANSPLANT(normal time constant) The second peak is alveolar GAS from DISEASED Lung.
90
Leak in sample time CO2 waveform?
The beginning of the plateau is low, because dilution of alveolar gas at atmospheric air is aspirated into the sample line. NOT SEEN WITH SPONTANEOUS VENTILATION.
91
Hyperventilation from increased MV lead to this electrolyte imbalance?
Metabolic acidosis
92
For ETCO2 to be detected, what must be met?
CO2 must be produced during metabolism Adequate pulmonary blood flow to deliver CO2 to lungs Adequate VENTILATION to transport CO2 to the breathing circuit INTACT SAMPLING SYSTEM
93
When answering question about ETCO2, answer these 2 things
What is the cause? | Does this affect the PaCO2 to ETCO2 gradient?
94
Causes of changes in ETCO2 can be divided into
Changes in CO2 Production: Impaired pulmonary perfusion, or /and Impaired ventilation Equipment malfunction
95
Normal PaCO2 to EtCO2 gradient
2-5 mmHg
96
A wide PaCO2 to EtCO2 gradient suggests
V/Q mismatch/ OR equipment malfunction
97
PaCO2 is _____Than EtCO2
Higher
98
The first thing that should come to mind with wide PaCo2 to EtCO2 gradient
INCREASED DEAD SPACE (such as hypotension, reduced CO / PE etc)
99
Increase Basic Metabolic RATE ( increase VO2) affect CO2 how ?
Increased CO2 (increased production)
100
MH affect CO2 how ?
Increased CO2 (increased production)
101
Thyrotoxicosis affect CO2 how ?
Increased CO2 (increased production)
102
Fever affect CO2 how ?
Increased CO2 (increased production)
103
Sepsis affect CO2 how ?
Increased CO2 (increased production)
104
Seizures affect CO2 how ?
Increased CO2 (increased production)
105
Laparoscopy affect CO2 how ?
Increased CO2 (increased production)
106
Tourniquet or vascular clamp removal affect CO2 how ?
Increased CO2 (increased production)
107
Sodium bicarbonate administration affect CO2 How?
Increased CO2 (increased production)
108
Anxiety affect CO2 How?
Increased CO2 (increased production)
109
Pain affect CO2 How?
Increased CO2 (increased production)
110
Decrease BMR (Vo2) affect CO2 How?
Decreased CO2 production and delivery to the lungs.
111
Increased anesthetic depth affect CO2 How?
Decreased CO2 production and delivery to the lungs.
112
Hypothermia affect CO2 how?
Decreased CO2 production and delivery to the lungs.
113
Decreased pulmonary blood flow affect CO2 how?
Decreased CO2 production and delivery to the lungs.
114
Decreased cardiac output affect CO2 how?
Decreased CO2 production and delivery to the lungs.
115
Hypotension affect CO2 how?
Decreased CO2 production and delivery to the lungs.
116
Pulmonary Embolusm affect CO2 how?
Decreased CO2 production and delivery to the lungs.
117
V/Q mistmatch affect CO2 how?
Decreased CO2 production and delivery to the lungs.
118
Medication side effect affect CO2 HOw?
Decreased CO2 production and delivery to the lungs.
119
Main mechanism of Increased ETCO2
Decreased alveolar ventilation
120
Decreased alveolar ventilation causes : RESP
Hypoventilation COPD Metabolic alkalosis (If spontaneous ventilation)
121
Decreased alveolar ventilation causes: NEURO
CNS depression Residual NMB High spinal NM disease
122
Main Cause of DECREASED ETCO2
Increase alveolar ventilation
123
Increased alveolar ventilation causes : RESP
Hyperventilation | Metabolic acidosis
124
Can cause either increase or decrease alveolar ventilation
Medication side effect
125
Inadequate ventilation on alveolar ventilation
Increase Alveolar ventilation
126
Equipment malfunction that would cause Increased ETCO2
``` Rebreathing CO2 absorption exhaustion Unidirectional valve malfunciton Leak in breathing circuit Increased apparatus dead space ```
127
Equipment malfunction that would cause Decreased ETCO2
``` Ventilator disconnect Esophageal intubation Poor seal with ETT or LMA Sample line leak Airway obstruction Apnea ```
128
The pulse oximeter utilizes which Law
Beer-Lambert Law
129
Pulse oximeter emits ____
2 wavelenghts of light
130
Pulse oximeter emits 2 wavelengths of light
oxygenated blood better absorbs near infrared light (940nm) | Deoxygenated blood better absorbs red light (660nm)
131
What does the pulse oximeter really look at ?
Ration of light absorption during the peak of the waveform relative to the trough of the waverform.
132
At the peak of the waveform, the
Ratio of arterial blood to venous blood is INCREASED>
133
The beer-lambert law relates
the intensity of light transmitter through a solution and the concentration of the solute within the solution. in this instance, the solution is blood and the solute is hemoglobin
134
The oxygen saturation determines
the color of the blood. Comparing the ratio of light absorption in arterial and venous blood.
135
Red light is preferentially absorbed by
Deoxyhemoglobin (higher in venous blood)
136
Near infrared light is preferentially absorbed by
Oxyhemoglobin (higher in arterial Blood )
137
For pulse ox, the amount of light absorbed
Changes throughout the pulse cycle
138
At the trough of the pulse ox waveform,
There is a greater amount of venous blood in the tissue sample
139
At the peak of the pulse ox waveform,
There is greater amount of arterial blood in the tissue sample.
140
SPO2 formulation
Oxygeated Hgb / Oxygenated Hgb + Deoxygenated | x 100%
141
SPO2 response time, as a general rule
The closer the monitoring site to the central circulation, the faster it will respond to ARTERIAL desaturation.
142
Central monitoring sites are more resistant to the
vasonconstrictive efrects of SNS stimulation and hypothermia
143
Sites of SPO2 From MOST to LEAST RESPONSIVE: FAST
Fast = EAR, nose, Tongue, esophagus forehead
144
Sites of SPO2 From MOST to LEAST RESPONSIVE: Middle
FINGER
145
Sites of SPO2 From MOST to LEAST RESPONSIVE: SLOW
TOE
146
When SPO2 is monitored on the head or esophagus,
THE Trendelenburg position can cause venous engorgement resulting in a FALSELY DECREASED SPO2 measurement.
147
SPO2 90%= PaO2 is ______
60 mmHg
148
SPO2 80%= PaO2 is ______
50 mmHg
149
SPO2 70%= PaO2 is ______
40 mmHg
150
SPO2 monitoring is most useful when the patient's
PaO2 aligns with the steep portion of the Oxyhemoglobin dissociation curve.
151
Left shift mean _____affinity
think L "Love to hold" Increased
152
Right shift mean ______Affinity
Decreased affinity (R for released)
153
CADET FACES RIGHT
Increased CO2 Acidosis (Increase H+) (decrease pH) Increased 2,3, DPG Increased temperature
154
LEFT shift is associated with
Decreased CO2 Alkalosis (decreased H+) (Increased pH) Decreased 2,3 DPG Decreased Tempature
155
Once the SPO2 reaching 100% on the plateau portion of the curve, you are no longer able to extrapolate the PaO2; it could be
100 or 500mmHg, either way the SPO2, will read 100%
156
5 Methods to improve the SPO2 signal
``` Performance of a digital block Warming the extremity Protecting the extremity from light Vasodilating crea Administer an arterial vasodilator. ```
157
Pulse oximeter is a useful monitor of
Vascular compression
158
Pulse ox is not a good monitor or
Ventilation Anemia Bronchial intubation
159
The pulse oximeter is a noninvasive monitor of
Hemoglobin saturation Heart rate Fluid responsiveness
160
Useful to asses perfusion?
Pulse oximeter
161
May be compressed during mediatinoscopy
The brachiocephalic (innominate) artery
162
Innominate artery supplies blood to
right arm, head and neck
163
First branch of the aortic arch?
Innominate artery
164
Third branch off the AORTA
Innominate
165
What are the 2 branches off the aorta
Left and right coronary arteries.
166
Where do you place pulse ox probe to monitor foot perfusion in the lithotomy position?
Placement on the toe
167
Pulse ox can monitor for shoulder arthroscopy?
Brachial artery compression during shoulder arthroscopy
168
Does the pulse oximeter monitor anemia?
NO
169
SPO2 monitors the
% of hemoglobin bound with oxygen
170
If the Hgb is fully saturate with oxygen, then the
SPO2 will continue to read 100%
171
2 parameters highly depended on the amount of Hgb
``` Oxygen carrying capacity (CaO2) Oxygen delivery (DO2) ```
172
May overestimated SPO2 with
Severe anemia.
173
Does the pulse oximeter monitor VENTILAITON
NO
174
Alveolar oxygen equation
Alveolar oxygen = FiO2 x (Pb - PH2O) - PaCO2/RQ
175
Just because a patient does not desaturate does not mean
The Endotracheal tube is not positioned in the left or right bronchus.
176
Assessment of bronchial intubation is better accomplished by
Presencee of bilateral breath sounds Chest X-ray Visualizing the CARINA through a fiberoptic bronchoscope.
177
Bronchial intubation and PIP
ACUTE rise in PIP during volume controlled ventilation may signal a bronchial intubation . As you withdraw the ETT, the peak inspiratory pressure and the pressure and flow volume should return to baseline.
178
How does the LVAD affect pulse ox reading?
Unlike a healthy heart that delivers pulsatile flow to the body, the LVAD supplements the failing myocardium with non-pulsatile flow.
179
How does the carboxyhemoglobin affect Pulse ox reading
Carboxyhemoglobin absorbs the same wavelength as oxyhemoglobin. This causes the pulse ox to overestimate the degree of oxygen bound to hemoglobin.
180
Nail polish and pulse ox reading
False reduction in SPO2
181
Pulse ox has a margin of error
2-3 percent when the SPO2 is between 70--100%
182
Margin of error for pulse ox 50-70%
3%
183
Dysfunctional oxygen species include
Methemoglobin | Carboxyhemoglobin
184
Methemoglobin absorbs
660nm ; 940 nm equally
185
Methemoglobin absorption
the 1:1 absorption ratio is read as 85%
186
Methomoglobin falsely underestimated SPO2 if O2 sat
>85 %
187
Methomoglobin falsely overestimated SPO2 if O2 sat
< 85%
188
Carboxyhemoglobin absorbs
660nm to the same degree as O2-Hgb
189
Decreased perfusion affecting SPO2
vasoconstriction Hypothermia Hypoperfusion Raynaud's syndrome
190
Altered optical characteristics affecting pulse ox
Dyes such as methylene blue, | Indocyanine green, and INDIGO CARMINE
191
Nail polish colors affecting pulse ox
Black Blue Green
192
Non-pulsatilve flow affecting pulse ox
CPB | LVAD
193
Motion artifact that affects pulse ox
shivering | movement and positioning of patient.
194
Factors that DO NOT AFFECT reliabiity of pulse ox
Jaundice Hgb F and S Polycythemia Acrylic finger nails.
195
What is the most common method of measuring exhaled gases inside the breathing circuit?
infrared absorption (each gas as signature fingerprint)
196
The greater the partial pressure of a gas inside the breathing circuit,
The greater the partial pressure of that gas delivered to the gas analyzer.
197
Infrared absorption spectrophotometry determines
Concentration and identities of all sample gases simultaneously
198
Does OXYGEN absorbed infrared light?
No
199
Concentration of OXYGEN MUST BE MEASURE BY WHAT MEANS?
1. GALVANIC CELL or clark electrode | 2. PARAMAGNETIC ANALYSIS
200
What is mass spectometry?
Bombards a gas samples with electrons creating ion fragments
201
New tool that can detect, inspired, expired and breath to breath changes of a particular gas by incorporating a lipid layer on the crystal?
Piezoelectric crystals.
202
Which phase of the CO2 waveform BEST corresponds to the ventilation-perfursion status?
Plateau phase (phase III)
203
CO2 follows a concentration gradient as it exits the body
Blood > lungs> Airway > Sample line or atmosphere.
204
Infraed anaylysis is the most common method of measuring
CO2, N2O Halogenated anesthetics.
205
Molecules that contain 2 or more dissimilar atoms do what?
absorb Infrared light
206
Why can't infrared analysis measure oxygen, helium, nitrogen or xenon
Becauses these species only contain ONE TYPE OF ATOM
207
Sampling methods with less apparatus dead space
Sidestream.
208
Response time with sidestream is
Slower
209
Red light 660nm is preferentially absorbed by
Reduced Hgb
210
Near infrared light (990nm) is preferentially absorbed by
HgbO2
211
SPO2 and mmHG | 40, 50, 60
70, 80,90 respectively
212
Determinants of dynamic compliance are
PEEP PIP TV
213
No changes in dynamic or status compliance with this?
PE
214
This causes decreased dynamic compliance
Mucus plus
215
This causes Decrease static compliance
Endobronchial intubation

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